Provider Demographics
NPI:1194175232
Name:IDAHO PERIO CENTER FOR DENTAL IMPLANTS & LASER PERIODONTAL THERAPY
Entity type:Organization
Organization Name:IDAHO PERIO CENTER FOR DENTAL IMPLANTS & LASER PERIODONTAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACE
Authorized Official - Middle Name:C
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD MS
Authorized Official - Phone:208-377-2777
Mailing Address - Street 1:6019 N EAGLE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-0997
Mailing Address - Country:US
Mailing Address - Phone:208-377-2777
Mailing Address - Fax:208-377-3075
Practice Address - Street 1:6019 N EAGLE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-0997
Practice Address - Country:US
Practice Address - Phone:208-377-2777
Practice Address - Fax:208-377-3075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-20
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-42901223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty